,
12 tweets,
3 min read
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1/ In which #UncleBob spends #5goodminutes discussing the strengths and weaknesses of guidelines - stimulate by the CAP discussion on twitter.
The idea of guidelines is to provide a guide for using evidence in diagnosis and management decisions.
@BradSpellberg @ABsteward
The idea of guidelines is to provide a guide for using evidence in diagnosis and management decisions.
@BradSpellberg @ABsteward
2/
Let's first start with some excellent guidelines:
1. Pts with HFrEF should have an ACE-I or ARB
2. Pts with known CAD should take an aspirin daily
3. Pts with anemia & CKD should be treated to a Hgb of ~11.5 and no higher
4. Pts with stable anemia do not need tx until Hgb < 7
Let's first start with some excellent guidelines:
1. Pts with HFrEF should have an ACE-I or ARB
2. Pts with known CAD should take an aspirin daily
3. Pts with anemia & CKD should be treated to a Hgb of ~11.5 and no higher
4. Pts with stable anemia do not need tx until Hgb < 7
3/
We would hope for a guideline for no more than 5 days of antibiotics in CAP patients stable after 3 days. Why? Because we have evidence of efficacy and less harm!
We would hope for a guideline for no more than 5 days of antibiotics in CAP patients stable after 3 days. Why? Because we have evidence of efficacy and less harm!
4/
Now the problems start. How do we develop a guideline for antibiotics. Antibiotics have at least 3 problems:
1. Resistance develops over time
2. Side effects become more apparent (FQs, vanc & pip/tazo)
3. New antibiotics become available.
Now the problems start. How do we develop a guideline for antibiotics. Antibiotics have at least 3 problems:
1. Resistance develops over time
2. Side effects become more apparent (FQs, vanc & pip/tazo)
3. New antibiotics become available.
5/
We rarely have evidence of a particular antibiotic or antibiotic combination compared with all alternatives.
Thus, any such guideline is "eminence" based rather than evidence based. Unfortunately this is the rule rather than the exception in ID guidelines:
We rarely have evidence of a particular antibiotic or antibiotic combination compared with all alternatives.
Thus, any such guideline is "eminence" based rather than evidence based. Unfortunately this is the rule rather than the exception in ID guidelines:
6/
Quality & Strength of Evidence of the IDSA Guidelines
academic.oup.com/cid/article/51…
Approximately one-half (median, 50.0%; interquartile range [IQR], 38.1%–58.6%) of the recommendations in the current guidelines are supported by level III evidence (derived from expert opinion). 💔
Quality & Strength of Evidence of the IDSA Guidelines
academic.oup.com/cid/article/51…
Approximately one-half (median, 50.0%; interquartile range [IQR], 38.1%–58.6%) of the recommendations in the current guidelines are supported by level III evidence (derived from expert opinion). 💔
7/
Evidence from observational studies (level II) supports 31% of recommendations (median, 30.9%; IQR, 23.3%–43.2%), whereas evidence based on ⩾1 randomized clinical trial (level I) constitutes 16% of the recommendations (median, 15.8%; IQR, 5.8%–28.3%)
Evidence from observational studies (level II) supports 31% of recommendations (median, 30.9%; IQR, 23.3%–43.2%), whereas evidence based on ⩾1 randomized clinical trial (level I) constitutes 16% of the recommendations (median, 15.8%; IQR, 5.8%–28.3%)
8/
In an effort to answer questions professional societies label their "expert opinions" as guidelines. They are not, and should be thus labelled. They should be a SEPARATE category of expert advice!
In an effort to answer questions professional societies label their "expert opinions" as guidelines. They are not, and should be thus labelled. They should be a SEPARATE category of expert advice!
9/
Furthermore, there is a problem with evidence interpretation. Otherwise how can one explain the guideline wars. Different organizations look at a clinical situation and develop conflicting guidelines. That should tell us something!
Furthermore, there is a problem with evidence interpretation. Otherwise how can one explain the guideline wars. Different organizations look at a clinical situation and develop conflicting guidelines. That should tell us something!
10/
Guidelines can harm patients. Guidelines can help patients. But we need true dispassionate guidelines. We need to stop labeling expert opinion as anything other than expert opinion.
Guidelines can harm patients. Guidelines can help patients. But we need true dispassionate guidelines. We need to stop labeling expert opinion as anything other than expert opinion.
11/
We need to prioritize making correct diagnoses before we start "following guidelines". We see too many pts receive perfect treatment for the wrong diagnosis, e.g., CAP (must really be a nickname for a possible infiltrate), bilateral cellulitis, heart failure, etc
We need to prioritize making correct diagnoses before we start "following guidelines". We see too many pts receive perfect treatment for the wrong diagnosis, e.g., CAP (must really be a nickname for a possible infiltrate), bilateral cellulitis, heart failure, etc
12/
I hope this screed produces intelligent debate and examples of good and bad guidelines. Will be happy to provide more examples if anyone so wishes.
Now #UncleBob drops the mic
I hope this screed produces intelligent debate and examples of good and bad guidelines. Will be happy to provide more examples if anyone so wishes.
Now #UncleBob drops the mic
